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* 1. Personal Information

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* 2. Tribal Affiliation (type N/A if not applicable) 

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* 3. Chapter House (if Navajo Nation Tribal Member)

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* 4. Age

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* 5. Birthdate

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* 6. Emergency Contact

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* 7. Do you identify as:

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* 8. Gender

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* 9. Ethnicity

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* 10. Racial Group

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* 11. Are you a U.S. Veteran?

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* 12. If yes, branch of service

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* 13. Are you an active member of the U.S. military?

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* 14. If yes, branch of service

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* 15. Do you have any family members actively serving in the military?

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* 16. Income level

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* 17. Housing

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* 18. Availability

  Mornings Afternoons Evenings
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* 19. How many mentorship hours are you able to accommodate per month? (minimum of 10 hours per month required)

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* 20. Why do you wish to be an Elder Mentor?

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* 21. Do you have past experience working with youth?

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* 22. If yes, what was your role/experience?

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* 23. How would you rate your technology abilities?

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* 24. Do you have reliable transportation?

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* 25. If not, do you utilize public transportation?

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* 26. Describe any skills, education, accomplishments, spiritual knowledge/language that you possess

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* 27. Are there any health issues, mobility issues, and/or accommodations that Phoenix Indian Center staff need to be aware of? (i.e. diet)

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* 28. As an AmeriCorps Seniors volunteer, you will be covered by accident and personal liability insurance, and a small death benefit while performing volunteer duties. This coverage is automatic and free of cost to you as long as you are an active, enrolled member of AmeriCorps Seniors. Please provide the following info

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* 29. Are you willing to complete a fingerprint clearance and background check?

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* 30. How did you hear about this opportunity?

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* 31. Do you prefer to do your interview via Zoom or In-Person at the Phoenix Indian Center.

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* 32. I understand that as an Elder Mentor, I will need to attend an orientation

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* 33. I understand that as an Elder mentor, I will need to complete required background checks and fingerprint clearance

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* 34. I understand that in my capacity as a Seniors Volunteer, I may come into contact with confidential information. I agree to protect this information to the best of my ability and not disclose it during or after my service as a volunteer had ended.

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* 35. I understand that if I use my personal automobile in my volunteer service, I will keep in effect automobile liability insurance equal or greater to the minimum requirement of the state of Arizona. I will also keep a valid Arizona State drivers’ license.

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* 36. Driver's License Information

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* 37. AmeriCorps Seniors provides mileage reimbursement to volunteers for travel between home and volunteer sites. Will you be claiming a mileage reimbursement for travel to and from your volunteer location?

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* 38. If yes, is a copy of your proof of auto insurance showing active coverage attached?

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* 39. Proof of auto insurance

By signing below, I certify that the information completed in this application is correct to the best of my knowledge.

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* 40. Print Name

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* 41. Today's Date

Date

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